Memory Brought to Mind. Five-Year Follow-Up of Case Finding and Intervention of Dementia in a Swedish Primary Health Care District.

BACKGROUND: In an urban/rural primary health care (PHC) district a five-year integrated project of early detection and management of cognitive disorders was made in collaboration between home care (HC) and family practice services using a single-item case-finding and intervention approach. OBJECTIVES: To assess feasibility, outcome and morbidity over a 5-year period. DESIGN, SETTING AND PARTICIPANT: In autumn 2008, the question "Have you experienced memory difficulties or been told of them by family members?" was mailed to all eligible persons > 75 years of age (n=367) in the urban/rural Vålberg HC and PHC district (population = 5073). 320 (= 87%; 184 no and 136 yes) responded and 117 yes-responders came for further examination. In the follow-up, all diagnoses up till November 2013 were collected and compared anonymously in both yes and no answerers. RESULTS: 114 completed examination. 29 showed low risk of cognitive impairment, 39 moderate and 46 high. Definitive diagnosis was obtained in 34 of the latter: 10 cognitive impairment, 16 Alzheimer's disease, 5 non-specific, 2 vascular and 1 alcoholic dementia. During follow-up no further dementia diagnoses occurred in the low, two in the moderate, and none in the high-risk group, versus 12 in the no responders. Age and mortality were significantly higher in the high-risk group. Co-morbidity was very frequent but did not differ between the groups. CONCLUSIONS: Population response and compliance were excellent; the single-item direct question approach gave workable results with in particular high negative predictive power persisting over the five-year follow-up period, and can be applied in early case-finding, prevention and intervention of cognitive impairment in an integrated local HC, PHC and Hospital setting.

Influence of carboxyhemoglobin, gamma-glutamyl-transferase, body weight, and heart rate on blood pressure in middle-aged men.

Carboxyhemoglobin (COHb%) and gamma-glutamyl-transferase (GGT) are indicators of tobacco and alcohol consumption; similarly, body weight broadly reflects dietary habits. Relationships between COHb%, GGT, relative body weight, heart rate and blood pressure were studied in 242 48-year-old men attending a general health screening program in Malmö, Sweden. All were without treatment for high blood pressure. Positive correlations were found between blood pressure and body weight, GGT, and pulse, and a reciprocal correlation between blood pressure and COHb%. Use of objective markers for known or suspected risk factors, such as alcohol consumption, smoking, or overweight, were studied to elucidate their usefulness for further prospective studies.

The effects of smoking, hypertension and cardiovascular disease on the estimation of unscheduled DNA synthesis and covalent binding to DNA induced by N-acetoxy-2-acetylaminofluorene in resting human mononuclear leukocytes.

The levels of N-acetoxy-2-acetylaminofluorene (NA-AAF)-induced unscheduled DNA synthesis (UDS) and of NA-AAF binding to DNA have been determined in resting mononuclear leukocytes from individuals with various smoking habits, heart infarct patients and subjects diagnosed for hypertension. Age-matched and blood-pressure-controlled smokers (n = 99) had significantly elevated levels of NA-AAF-induced UDS and NA-AAF binding to DNA when compared to nonsmokers (n = 75) similarly corrected for age and blood pressure. Heart infarct patients without any history of risk factors, as well as diagnosed hypertensives with normalized blood pressure, were not significantly different from matched controls when assessed by the NA-AAF method. Our results support the theory that increased mutagen sensitivity is associated with smoking and high blood pressure but not with cardiovascular disease itself via some mechanism of genetic selection.

Premature death and associated risk factors in urban middle-aged men.

The full range of premature mortality and associated risk factors was analyzed for a follow-up period of three and a half to eight years in a uniform group of 7,935 middle-aged males (46 to 48 years old at screening) participating between the years 1975 and 1979 in the preventive population program in Malmö (participation rate 76.7 percent). Of the 218 deaths that occurred, necropsy was performed in 181 (83.0 percent). Three major causes of death were established: cancer (61/218), alcohol-related deaths (55/218), and coronary heart disease (50/218). In these three main categories of male premature mortality, significant and distinctly differential risk factor patterns were found. In coronary heart disease, smoking (p = 0.0062), serum cholesterol level (p = 0.00014), serum triglyceride level (p = 0.00013), systolic blood pressure (p = 0.000012), and diastolic blood pressure (p = 0.0021) were the strongest single determinants, but the independent role of the diastolic blood pressure disappeared in a multivariate analysis whereas all the others could be combined in a highly predictive logistic model. In the alcohol-related group, equal or stronger risk factor associations were present for serum gamma-glutamyltransferase level (p less than 0.0001), questionnaire alcoholism screening response (p less than 0.0001) and, inversely, serum cholesterol level (p = 0.0046) and serum creatinine level (p less than 0.0001), all of which were independent and could be combined in an even more predictive logistic model than in the coronary heart disease group. In the cancer deaths, significant associations were found for serum urate level (p = 0.023) and, inversely, serum cholesterol level (p = 0.056 - 0.031). Malignant and alcohol-related diseases constituted at least equally prominent groups as the cardiovascular disorders of the total premature deaths that occurred during middle age in these cohorts of Malmö males. All of these conditions are potentially avoidable and seem to be associated with significant and distinctive risk factor patterns. It seems possible that these factors may be applied, in current alcohol-related disorders and in future malignant diseases, both as indicators of the respective risks and as signals and instruments for directed preventive measures like the previously well established and tested methods for the regulation of blood pressure, serum lipids levels, and so on.

Aryl hydrocarbon hydroxylase induction levels in patients with malignant tumors associated with smoking.

The levels of aryl hydrocarbon hydroxylase (AHH) inducibility were assessed in 173 patients with cancers statistically associated with smoking, i.e., squamous cell and transitional cell carcinomas, at various sites. In 34 patients with carcinomas of the oral cavity, 41 patients with laryngeal carcinomas, and 22 patients with pulmonary carcinomas there was a highly significant overrepresentation of high inducers, whereas 30 patients with carcinomas of the renal pelvis and ureter and 46 patients with urinary bladder carcinomas did not differ significantly in this respect from a control population comprising 92 subjects with no history of neoplastic disease. The results add further support to the concept of AHH as a major activator of carcinogens belonging to the group of polycyclic aromatic hydrocarbons (PAH) when these affect the oral cavity and/or the respiratory tract. The role of AHH in urothelial carcinogenesis seems to be less explicit.

Smoking habits and carboxyhaemoglobin. A cross-sectional study of an urban population of middle-aged men.

In this cross-sectional population study we report on the distribution of carboxyhaemoglobin concentrations in the morning, before smoking, in an urban population of 1037 men born in 1931. The median concentration was the same in non-smokers as in ex-smokers: 0.5%. It increased with increasing daily tobacco consumption. But when carboxyhaemoglobin concentrations are measured in reasonably well-standardised circumstances there are large variations between individuals, even in those who smoke equal amounts of tobacco a day. This makes it difficult to predict the concentration in the individual smoker when only his daily tobacco consumption is known. Measurements of carboxyhaemoglobin concentration should be a valuable complement to smoking history to identify the smoker at high risk of cardiovascular disease, to provide an extra argument to make the patient give up the habit, and to reinforce the efforts of those who try to do so.

Serum ferritin, gammaglutamyl-transferase and alcohol consumption in healthy middle-aged men.

Serum ferritin was analysed in 169 middle-aged men. Ninety-one were heavy drinkers with increased serum gammaglutamyltransferase (GGT) values in otherwise normal routine screening tests; 39 were from the same birth year cohorts with normal GGT values; and 39 were teetotalers. Increased ferritin values were found in 67% of the heavy drinkers, but only in 2.5% in the two other groups. The mechanisms of the serum ferritin elevation in otherwise healthy alcohol over-consumers are unknown, but heavy drinking should be taken into consideration in the interpretation of increased serum ferritin values in individual cases.

Comparison of gamma-glutamyltransferase and questionnaire test as alcohol indicators in different risk groups.

gamma-Glutamyltransferase (gamma-GT) and a Malmö modification of the Michigan Alcoholism Screening Test (Mm-MAST) were compared in subsamples of a health screening population of urban middle aged males with characterized levels of alcohol consumption and in the total group of deaths 0-6 years after the screening investigation. The questionnaire was markedly superior to gamma-GT in identifying the alcohol consumption in the known alcoholics but not in the other study groups. gamma-GT may be indicative of alcohol related health disturbances and may be used in their early recognition and as biochemical feedback in their further treatment and control in individuals. It may therefore be of value particularly as an instrument in a programme aimed at prevention of alcohol-related health complications.

Hospitalization and alcohol-related morbidity within three years after screening in middle-aged men.

All men living in Malmö who were born in 1926-1929 were invited for a health screening examination which included, among many other things, measurement of gamma-glutamyltransferase (GGT). They were followed up and within three years after the screening 963 of 4571 men had been hospitalized. They had 17158 hospital days or almost 6 days per individual each year. The impact of alcohol on the admissions was analysed both according to the International Classifications of Diseases and a new design where all the diagnoses were grouped and coded in conditions which were judged to be alcohol-related, potentially alcohol-influenced and non-alcohol-related. Of the total days in hospital, alcohol psychosis and alcoholism accounted for 13.6 per cent. Altogether 29.2% of the days were caused by alcohol-related and potentially alcohol-influenced conditions. GGT values at the screening investigation were significantly increased in 25% of the hospitalized men. Alcohol-related admissions were seven times as many in men with GGT values in the highest quintile compared with those who had values in the lowest quintile.

Unwinding Ariadne's thread: some methodological and interpretative considerations on international hospital admission comparisons, with special reference to cancer.

Hospital utilisation rates comprise the main available source of information on morbidity patterns and the need for health care in a number of developing countries. On the basis of the findings of a Greek-Swedish comparison of somatic hospital admission (presented per the 18 principal head groups of the International Classification of Diseases) between two regional University hospitals, a number of important findings and methodological questions are considered. Factors that can explain the large variations of hospital admission found are examined; in particular those related to disease definition, classification and coding, hospital services supply, professional behavior and practices, illness behavior of patients, and demographic and socio-economic characteristics but especially a true difference in morbidity. An additional statistical elaboration of the hospitalization data in the form of a logistic regression analysis is suggested, in particular at the district or regional level. However, after rigorous scrutiny, our data point to persistent remarkable differences at the respective sites in the major "welfare-related" population diseases, notably, cancer and cardiovascular diseases.

Smoking, carboxyhaemoglobin, carbon monoxide in expired air and aryl hydrocarbon hydroxylase inducibility. A cross-sectional study and anti-smoking applications in middle-aged men.

In this cross-sectional study we report on the distributions of carboxyhaemoglobin in blood (COHb%), carbon monoxide in expired air (CO), and aryl hydrocarbon hydroxylase (AHH) inducibility in age-matched samples of males born 1934-36 and 1921, attending our ongoing preventive medical health screening program in Malmö. Both COHb% and CO showed great interindividual variations in the smokers; potentially of value as a complement to smoking history to identify smokers at high risk of tobacco-related diseases. They also provide powerful arguments for quitting smoking. Therefore, CO is now measured and discussed by the nurses as part of the screening investigation in all smokers. Neither COHb% nor CO showed correlations to the AHH induction levels. There were no associations between the latter and the smoking category, which supports that AHH inducibility is under genetic control. However, high AHH induction in smokers implies an increased risk of smoking-induced carcinogenesis. Smokers with high AHH inducibility identified in the screening have, therefore, been invited to antismoking information and counselling.

Differential cancer morbidity towards year 2000 in a population disease outlook across Europe.I. The female gender.

Modern health system research emphasises the transition from mortality statistics via morbidity and risk factors observations to comparative site explorations in defined areas. The health of women from the perspective of their gender has become a priority in medical research over the last decade. Studies of morbidity have been called for as necessary intermediary stage for hypothesis generation, and the formulation and inception of epidemiological projects which are recognized as essential for attaining knowledge on the factors and circumstances that determine diseases and wellbeing in the general population. This applies especially to cancer, where the importance of seeing disease, from a ecological, cultural as well as gender context is evident. We made a comparative analysis of the hospitalization for somatic diseases during 1986-1987 at the Heraklion University Hospital on Crete, and the commensurable Linköping University Hospital in the country of Ostergötland, Sweden. They are representative of their complementary Europian situations and comprise the total hospital admissions in their regions. Large differences were found, notably regarding both cardiovascular diseases and cancer, with lower morbidity in the more 'arcadian', rural circumstances. The results provide unique data on traits and patterns intermediate to the pioneering observations of the Seven Countries survey on the rapidly changing European scene. In the field of cancer the data are effectively unmatched both as raw data and as a platform for further investigation, which we are presently pursuing under the emblem of 'Ariadne's thread'. From a salutogenetic point of view the elderly rural women on Crete, and from a pathogenetic point of view the elderly urban women in Linköping warrant particular attention.

Relation between aryl hydrocarbon hydroxylase inducibility, serum gamma-glutamyltransferase and serum cholesterol in middle-aged smokers and non-smokers.

Aryl hydrocarbon hydroxylase (AHH) inducibility, carbon monoxide in expired air (CO), serum gammaglutamyl-transferase (GGT), and total cholesterol were compared in equal-sized, age-matched samples of healthy middle-aged males born in 1921, 1934-1936, and 1946 attending the ongoing preventive medical population program in Malmö. AHH did not differ in various age - and smoking or non-smoking groups, and there were no correlations between AHH, GGT, and cholesterol. The findings provide evidence against the recent hypothesis that low cholesterol may mediate or reflect a carcinogenic mechanism through a state of general enzyme induction in the body.

Differential cancer morbidity towards year 2000 in a population disease outlook across Europe. II. The male gender.

The conception of new, 'avoidable' life style diseases in affluent Western societies is largely based upon observations in groups of middle-aged urban males with mortality as the major end-point. This applies to cancer, too, and studies of morbidity, where cancer is put within the overall disease spectrum, are called for as a necessary intermediary stage for hypothesis generation and initiation of evaluative and interventive epidemiological projects in the community. Here also the conditions and circumstances that determine health and well being, that is, salutogenetic factors, come increasingly into focus. We made a comparative analysis of the total hospitalization for somatic diseases during 1986-1987 at the Linköping University Hospital in the county of Ostergötland, Sweden and the both complementary and commensurable Heraklion University Hospital on Crete. They are representative of their respective European situations, and are the only somatic hospitals in their regions. Large differences were found with lower morbidity in the more 'Arcadian', rural settings. The results provide valuable data on traits and patterns between earlier surveys such as the Seven Countries study and today. We have earlier reported on the findings from the female group of the two populations, and here wish to concentrate on the males. In particular, cancer is compared with the both prominent and 'archetypical' forms of male ill-health that are comprised by cardiovascular diseases and accidents. We discuss some of the salutogenetic as well as pathogenetic factors that call for closer study in the next stage of our project, whose emblem of Ariadne's thread we feel also has a strong bearing on the masculine gender.

Hospital admissions for different cancer diagnosis: a comparison between two European landscapes.

Cancer frequency has been studied in a Department of Crete and a Department of Sweden, using in-patient data collected in the Departmental Hospitals, for a two-year period. The results of the study suggest that similar trends exist in the prevalence of different forms of cancer between the two areas studied, as well as some significant differences. The differences observed concern mainly the frequency of cancers of the lung, prostate, bladder and large bowel among men and breast and large bowel among women. These findings could to a great extent be explained by life-style and environmental differences between the two areas and are consistent with data concerning the cancer mortality in the two countries.

Treatment perspectives in rheumatoid arthritis: a descriptive study in a Swedish healthcare district.

This study analyses patterns of treatment offered to individuals with a clinical diagnosis of rheumatoid arthritis (RA). A cross-sectional investigation was carried out in 321 patients (aged greater than 16 years) fulfilling the 1958 American Rheumatism Association (ARA) criteria for RA. Medical records were scrutinised retrospectively for information about medical, surgical and other treatments during a 5-year period (1982 to 1986). All patients had received medical treatment, but a large number had discontinued drug therapy because of adverse effects or lack of efficacy. 45.9% of the individuals were receiving 1 drug at the time of the survey, 33.8% were on 2 drugs, 11.7% were on 3 or 4 drugs, and 8.6% were not receiving any medication. Nearly 50% of the patients had had various kinds of surgical procedures performed. The clinical manifestation of the disease, as measured by the number of ARA criteria fulfilled, showed a linear correlation to nearly all medical and surgical treatments. A primary healthcare physician was the basic contact person for 90% of the patients, but in addition 70% of the participants had been examined at sometime by a rheumatological specialist. The study confirms our expectations that patients with RA receive numerous pharmaceutical and other treatments. Even patients with mild and/or early disease (probable RA) had received a considerable amount of treatment. Qualified specialised care was also provided despite the distance to a university referral centre.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlations of serum lipids and lipoproteins with gamma-glutamyltransferase and attitude to alcohol consumption.

The correlation of three markers of alcohol consumption: serum concentration of gamma-glutamyltransferase (GT), high density lipoprotein cholesterol (HDL-cholesterol), apolipoprotein AI (Apo AI), and the results of a questionnaire (Mm-MAST) designed to measure the attitude towards alcohol consumption were determined in a population of healthy men aged 48 years. Apo AI (r = 0.27) and GT (r = 0.31) were correlated (P less than 0.001) to the questionnaire score to a similar degree while the correlation between HDL-cholesterol and the questionnaire score was (r = 0.18), somewhat less good but statistically significant (P less than 0.01). There was no correlation between GT and HDL-cholesterol or Apo AI.

Serum gamma-glutamyl transferase and a somatic health score in middle-aged men.

In an ongoing population investigation of middle-aged men in Malmö, Sweden, several health screening variables showed strong but crude individual covariations with the level of the hepatic enzyme, serum gamma-glutamyl transferase (GGT). These variables were combined, according to an analysis of their normal distributions, into a score index which exhibited a much smoother correlation with low, normal, and elevated levels of GGT when tested in a random population subsample. It is concluded that this scoring system may find further utilisation as a general descriptive method of recording statistical covariations between health screening tests and sum them up.

Problem-based medical education in general practice: experience from Linköping, Sweden.

Medical services which are better suited to the needs of the community are increasingly demanded, for example by national governments, and depend to a great extent on education of the new generations of doctors. Problem-based learning in general practice at the community level represents a method of providing appropriate education. This paper describes some of the experiences of undergraduate and continuing medical education at the Faculty of Health Sciences, Linköping University, Sweden, which since 1986 have been entirely problem-based. General practice forms the backbone of the curriculum and is its largest subject. Problem-based learning in general practice and quality assurance have much in common. This applies over the spectrum of lifelong education, from the undergraduate curriculum through vocational training to later stages of continuing medical education. Involvement and understanding, a feeling of purpose, sharing and cooperation and a wish for self-improvement are all stimulated by the problem-based method. This approach has helped in the creation of a curriculum with general practice as the largest contributor, with early contact with patients in the community, and with ordinary general practitioners as teachers, tutors and examiners in spite of a relatively poorly developed primary care organization.

Prevention of alcohol-related problems in urban middle-aged males.

More than 30,000 individuals have been investigated in the continuous screening and intervention study in Malmö. Large subsamples of individuals with different levels of GGT (gamma-glutamyltransferase) have been characterized. GGT has proven to be a useful and simple tool in tracing, identifying, treating and controlling heavy drinkers. Furthermore, GGT seems to be a new and strong indicator of alcohol-related disabilities and short term mortality in the male population. Individuals with GGT in the tenth deecentile of the GGT distribution have been randomly selected for treatment or control. Results and follow-up for 60 months in the intervention study with randomized controls in middle-aged heavy drinkers indicate a significant reduction in alcohol consumption, sick absence, hospitalization and mortality. Thus, the intervention program seems to be effective in preventing complications of alcoholism on an individual basis.